Human Immunodeficiency Virus Infection in Transfusion Recipients
and Their Family Members

CDC has received a report of human immunodeficiency virus (HIV)
infection among multiply-transfused leukemia patients in New York
City. In addition, there have been several reports that persons
with
transfusion-associated HIV infection have transmitted the virus to
their sexual partners and newborn children. All infected
transfusion
recipients described in these reports had received blood or blood
components before routine screening of donated blood for HIV
antibody
was begun in the spring of 1985.
Multiply-Transfused Leukemia Patients

During the past year, four long-term leukemia survivors at
Memorial Sloan-Kettering Cancer Center in New York City developed
unexplained fever, weight loss, diarrhea, or lymphadenopathy. They
subsequently had positive serological tests for HIV antibody. A
retrospective study of other multiply-transfused leukemia patients
was
conducted to determine how many had been infected with HIV.
Informed
consent was obtained from all living patients. Positive enzyme
immunoassay (EIA) tests were confirmed by Western blot assay.
Patients known to have other risk factors for HIV infection were
excluded from the study.

Sera were located for 182 deceased and obtained from 22
surviving
leukemia patients treated during the years 1978-1986. Sixteen of
these transfusion recipients were seropositive for HIV antibody
(Table
1). They had received a mean of 27 units of packed red blood cells
(range 2-56) and 137 units of platelets (range 10-483). Forty-five
percent of these 204 patients had acute myelogenous leukemia; 20%
had
acute lymphocytic leukemia; 13%, chronic myelogenous leukemia; 4%,
chronic lymphocytic leukemia; 6%, myelodysplastic syndromes; and
12%,
other or unclassified leukemias. There was no correlation between
type of leukemia and the presence of HIV antibody. An additional
23
newly diagnosed, untreated, and untransfused leukemia patients were
tested and all were seronegative.
Additional Case Reports From Other Areas

Case 1: An elderly man with no known risk for AIDS received
multiple units of blood in early 1982, including one from a donor
who
subsequently tested positive for HIV antibody. The recipient
developed Pneumocystis carinii pneumonia (PCP) in 1983 and died in
1984. His wife, who did not have any other risk factors for AIDS,
had
had vaginal intercourse with him until he became ill in late 1982.
In
late 1984, her HIV antibody test was positive and she was diagnosed
as
having a type of lymphoma indicative of AIDS (1).

Case 2: A pregnant woman with no other risk factors for AIDS
received four units of blood in 1978, including one from a donor
who
later tested positive for HIV antibody. A son, born in 1980, had
failure to thrive beginning at 13 months of age and died with PCP
in
1986. The woman, her son, her husband, and the child born shortly
after the transfusion all tested positive for HIV antibody.
Reported by DA Scheinberg, MD, PhD, GY Minamoto, MD, K Dietz, MS,
JWM
Gold, MD, T Gee, MD, D Armstrong, MD, J Gabrilove, MD, B Clarkson,
MD,
N Chein, MS, L Reich, MD, Memorial Sloan-Kettering Cancer Center,
DL
Morse, MD, State Epidemiologist, New York State Dept of Health; M
Batt, MD, Lutheran General Hospital, Park Ridge, HJ Miller, MD,
Dept
of Medicine, Evanston Hospital, Evanston, B Stevko, MD, Illinois
Dept
of Public Health; LA Chambers, MD, American Red Cross Blood
Services--Northeast Region, Dedham, L Kunches, GF Grady, MD, State
Epidemiologist, Massachusetts Dept of Public Health; Div of Blood
and
Blood Products, Center for Drugs and Biologics, FDA; AIDS Program,
Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: At present, prevention of HIV infection and AIDS
is
dependent upon deferral of blood or plasma donation by persons at
increased risk for AIDS, testing of donated blood and plasma for
HIV
antibody, heat treatment of clotting factor concentrates, avoidance
of
unprotected sexual contact and needle sharing by persons infected
with
HIV, and prevention of perinatal transmission by infected women.
Counseling and HIV antibody testing have been recommended for
persons
at risk for infection (including homosexual/bisexual men,
intravenous
drug abusers, hemophilia patients, prostitutes, and persons who
have
had sexual contact with members of these groups) (2). Routine
counseling and antibody testing have not been recommended for blood
transfusion recipients because, in general, their risk for
infection
is extremely low. However, as illustrated by this report and
others
(3), some multiply-transfused persons may be at a higher risk for
HIV
infection. In addition, some persons with transfusion-associated
HIV
infection have transmitted the virus to their sexual partners and,
perinatally, to their infant children.

Although the number of infected transfusion recipients in the
United States is unknown, it can be approximated using estimates of
the prevalence of infection in donors, the efficiency of
transmission,
and the number of units transfused per year. In 1985, 0.04% of
donations were positive for HIV antibody by Western blot assay (4).
If 0.04% had been the seroprevalence among donors in the year prior
to
screening, if all seropositive units had transmitted infection (5),
and if each seropositive unit had gone to a different recipient,
then
7,200 of the approximately 18 million components transfused in 1984
(American Blood Commission, unpublished data) might have
transmitted
infection. If 60% of these recipients have died from their
underlying
disease (6), then approximately 2,900 living recipients who
acquired a
transfusion-associated HIV infection in 1984 would remain. Most of
these would be asymptomatic. The number of infected donors was
probably lower in earlier years. Mathematical projections from
reported transfusion-associated AIDS cases estimate that
approximately
12,000 people now living in the United States acquired a
transfusion-associated HIV infection between 1978 and 1984 (7).

Blood banking organizations in the United States have begun
"look-back" programs to identify previous recipients of blood from
donors who tested positive for HIV antibody after screening began.
In
one region, 70% of recipients identified through such a program had
HIV antibody (8). However, look-back programs cannot identify all
infected transfusion recipients because many infected donors may
have
refrained from donating or become too ill to continue to donate
after
HIV serologic testing of donors began.

The risk of HIV transmission by transfusion was low, even
before
screening, and has been virtually eliminated by the routine
screening
of donated blood and plasma. However, since HIV-infected persons
are
at risk for developing AIDS or related conditions themselves and
may
transmit infection to others, physicians should consider offering
HIV
antibody testing to some patients who received transfusions between
1978 and late spring of 1985. This consideration should be based
on
the likelihood of infection in a recipient and the likelihood of
transmission from that recipient. The risk of infection is
greatest
if the recipient received large numbers of transfusions and if the
blood was collected during the few years before screening in an
area
with a high incidence of AIDS. (The leukemia patients in this
report
received many units of blood and blood components in an area with a
higher prevalence of HIV than most parts of the United States, so
their seropositivity rate is higher than would be expected in other
patients. Conversely, persons who received a small number of units
in
a low prevalence area would have an extremely low risk of HIV
infection.) Testing is particularly important if the patient is
sexually active. Since the overall prevalence of infection in
transfusion recipients is expected to be low, the positive
predictive
value of EIA screening tests for HIV antibody will be much lower
than
that seen when testing high-risk populations (9). Therefore, all
transfusion recipients with a positive EIA should also have their
serum tested by a second method (Western blot assay,
immunofluorescence assay) before they are informed of their test
result. Seropositive persons should be evaluated for signs and
symptoms of AIDS or related conditions and counseled regarding the
avoidance of HIV transmission to others.

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